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1、室性心律失常的临床处理贵州省人民医院杨龙内容特发性室性早搏特发性室性心动过速获得性尖端扭转型室速急性心肌梗死相关室速慢性心力衰竭相关室速一、特发性室性早搏治疗与否？药物？消融？（一）选择治疗的理由症状。心脏重构：导致心脏扩大、心功能减退。InpatientswithfrequentPVCsandnoorganicheartdisease,whoareatlowriskofsuddencardiacdeath,adecreaseinQOL(QualityOfLife)andseverityofsymptomsarethemainindicationsfortreatmentwithantiarr
2、hythmicagents.ZipesDP,etal.JAmCollCardiol,2006.AliotEM,etal.HeartRhythm,2009.Twohundredandthirty-nineconsecutive patients presentingwith frequent PVCs(>1000beats/day) originating fromtheRVOTor LVOT withoutanydetectableheartdiseasewereenrolledinthestudy.Duringanobservationperiodof5.6(1.7)years,therew
3、asasignificantnegativecorrelationbetweenthePVCprevalenceandDeltaLVEF(p<0.001)andpositivecorrelationbetweenthePVCprevalenceandDeltaLVDd(p<0.001).NiwanoS,etal.Heart,2009.室早频率与心室重构室早频率与心室重构StudieshavedocumentedthathighlyfrequentPVCs(>20,000beats/day)orbaselinedecreasedLVEFexhibitasignificantdecreaseinL
4、VEFduringlong-termfollow-up.NiwanoS,etal.Heart,2009.BogunF,etal.HeartRhythm,2007.Theuseofmetoprolol,propafenoneandverapamilisrecommendedinpatientswithPVCsofRVOTorigin.ZipesDP,etal.ACC/AHA/ESC2006guidelinesformanagementofpatientswithventriculararrhythmiasandthepreventionofsuddencardiacdeath.JAmCollCa
5、rdiol,2006.（二）药物治疗Beta-blockershavebeentestedinpatientswithidiopathicPVCs.Theirefficacywasmodest(25%formetoprolol)ornotsuperiortoaplacebo(atenolol).CapucciA,etal.ClinCardiol,1989.SaikawaT,etal.JpnHeartJ,2001.KrittayaphongR,etal.AmHeartJ,2002.Patientswereincludedinthestudyiftheyhad:(1)symptomatic(>4w
6、eeks)monomorphicPVCs>2,500/24h;or(2)persistent(>3months)monomorphicPVCs<2,500/24hwithsimilarPVCs(<20%difference)ontworepeatedHoltermonitorings,butseveresymptomsclearlyassociatedwithPVCs.StecS,etal.KardiolPol.2012.Benignsymptomaticprematureventricularcomplexes:short−andlong−termefficacyofantiarrhythm
7、icdrugsandradiofrequencyablationStecS,etal.KardiolPol.2012.32%4WStecS,etal.KardiolPol.2012.InthegroupofpatientswhounderwentRFCA,long-termefficacyof88%wasachievedduringlong-term(48±10months)follow-up.对
